Depression is a recurrent, common disorder during adolescence and may occur more often at this time than any other life stage [
Depression is a multi-factorial syndrome, so associated factors need to be evaluated to provide a complete understanding of depression starting in adolescence. There are evidences showing that some psychosocial factors may increase depression risks among adolescents [
Denollet introduced “Distressed Personality” and developed the type D personality. It is defined as the interaction of negative affectivity (the tendency to experience the negative emotions) and social inhibition (the tendency to inhibit the expression of these emotions in social interaction) [
Family environmental factors may also contribute to the development of depressive symptoms among adolescents. Studies reported that depressed children expressed lower levels of satisfaction and cohesion, higher levels of conflict than did controls [
While there is considerable research focusing on the relationship of depression and other correlated factors in adolescents; for example, high overprotection from parents, low self-esteem, and negatively coping style, as well as maternal depression had been investigated as predictors of youth depression [
Adolescent patients with initial depression were derived from the psychological clinic of Xinxiang second hospital, Xinxiang Medical College, from May to October, 2005. Diagnoses were obtained by two specialized professors according to DSM-IV criteria for depression. Depressive symptoms were assessed using the Structured Clinical Interview for the DSM-IV(SCID-I) [
Ninety-four patients were screened for study, five patients were excluded due to not finishing all scales eventually, and three patients refused to participate. The final patient sample consisted of 86 patients (45 males and 41 females), with a mean age of 16.1 years (SD = 1.7). In terms of education, the sample consisted entirely of high school students. The depressed adolescents stem from three different sorts of schools: key high school, ordinary high school, and vestibule school (In China, the construction of high school include these three sorts, whose purpose lie in cultivating different school work orientation after graduation.) We built up the pool sampling in our current investigation from the previous three different sorts of high schools, including 830 healthy high school students. According to matching principal (depressed group/control group 1 : 1.5), 120 students were drawn off in pool sampling, nine were excluded due to not finished overall scales, and three were unwilling to participate in this activity. The control sample actually consisted of 108 students (61 males and 47 females), with a mean age of 16.1 years (SD = 1.6). The scores of Zung self-rating depression scale below 50 (SDS < 50) in these participants. Written informed consent was obtained from the study participants and their parents. The Ethics Committee of Xinxiang Medical College approved the study protocol.
All measures were administered in Chinese. At the beginning of the session, the depressed and healthy adolescents were briefly informed of the goals of this study, the questionnaires were completed anonymously, and the following measures were obtained:
Questionnaire included information about demographic and socioeconomic factors such as age, gender, parents’ education levels, parents’ age, family structure (intact or single parents), and household income (reflection of socioeconomic status). We need to examine relationships between these factors and depression. See Table
Demographic characteristics of study sample.
Depression | Normal Controls | |||
---|---|---|---|---|
16.1 ± 1.7 | 16.1 ± 1.6 | 6.380 | .380 | |
.334 | .663 | |||
male | 45 (52.3%) | 61 (56.5%) | ||
female | 41 (47.7%) | 47 (43.5%) | ||
4.339 | .051 | |||
middle school | 38 (44.2%) | 32 (29.6%) | ||
high school | 48 (55.8%) | 76 (70.4%) | ||
1.627 | .435 | |||
≤middle school | 26 (30.2%) | 25 (23.1%) | ||
high school | 36 (41.9%) | 54 (50.0%) | ||
>high school | 24 (27.9%) | 29 (26.9%) | ||
2.026 | .369 | |||
≤middle school | 35 (40.7%) | 36 (33.3%) | ||
high school | 39 (45.3%) | 60 (55.6%) | ||
>high school | 12 (14.0%) | 12 (11.1%) | ||
43.7 ± 4.4 | 42.7 ± 3.8 | 33.863 | .129 | |
42.9 ± 4.5 | 41.2 ± 3.4 | 32.654 | .136 | |
.312 | 1.000 | |||
Two parents | 82 (95.3%) | 102 (94.4%) | ||
Single parent | 1 (1.2%) | 2 (1.9%) | ||
Neither-parent-living | 3 (3.5%) | 4 (3.7%) | ||
1.200 | .630 | |||
Below average | 7 (8.1%) | 9 (8.3%) | ||
Average | 77 (89.5%) | 93 (88.0%) | ||
Above average | 2 (2.4%) | 6 (3.7%) |
Note: Chi-Square test adopted Fisher’s value of exact probability; % represented composing percent.
The LOT-R is a 10-item scale that assesses subjects’ expectations about their future and their general sense of optimism. The LOT-R is comprised of 3 positively worded (e.g., I’m always optimistic about my future) and 3 negatively worded items (e.g., I hardly ever expect things to go my way). Each item is rated on a five-point Likert type scale ranging from zero (strongly disagree) to four (strongly agree). The LOT-R has been shown to be a reliable and valid measure of optimism in North American [
The DS-14 is a 14-item scale that assesses type D personality. Each item is rated according to a five-point Likert scale from zero (
The FES-CV measures the social-environmental characteristics of families based on a three-dimensional conceptualization of families. It measures three different dimensions with 10 subscales, including cohesion, expressiveness, conflict, independence, achievement orientation, intellectual-cultural orientation, active recreational orientation, moral-religious emphasis, organization, and control measures. Scores for each of these 10 subscales are derived to create an overall profile of family environment. FES-CV exhibited satisfactory psychometric qualities, the internal consistency Cronbach’s
The SDS is 20-item scale designed to assess the level of depression for individuals. The scale consists of ten positively worded and ten negatively worded questions that rate the four common characteristics of depression: the pervasive effect, the psychological equivalents, other disturbances, and psychomotor activities. Each item on the scale is scored on a scale of 1 (little of the time) to 4 (most of the time), Scores range from 25–100, with higher scores indicating higher levels of depressive symptoms. Chinese researchers has constructed Chinese population norm [
The chi-square test was used to examine the differences between two groups on demographic variables, such as gender, mean age, educational levels for adolescents, and parents’ mean age, educational levels, family structure, and family economic status. An analysis of multiple dependent variables was employed for multiple comparisons between groups on continuous variables by performing multiple
All analyses were performed using the Statistical Program for Social Sciences (SPSS), Version 13.0 for Windows. All statistical significance was set at
The demographic characteristics of study sample are shown in Table
Our first aim was to examine whether adolescents with depression have lower optimistic cognitive style, predominant type D personality, and more adverse family environment than normal controls (refer to Table
Comparison of LOT, DS, and FES between two groups
Factor | Depression | Normal controls | ||
---|---|---|---|---|
Optimism | 7.62 ± 3.20 | 12.02 ± 2.07 | −11.59 | .000 |
Pessimism | 7.54 ± 1.98 | 6.59 ± 1.88 | 3.37 | .001 |
LOT-total | 14.21 ± 3.74 | 19.56 ± 2.76 | −11.45 | .000 |
Negative affective | 14.83 ± 6.18 | 5.89 ± 4.55 | 11.60 | .000 |
Social-Inhibition | 14.90 ± 6.04 | 8.52 ± 5.16 | 7.92 | .000 |
DS-Total | 29.72 ± 11.29 | 14.41 ± 8.36 | 10.85 | .000 |
Cohesion | 5.56 ± 2.66 | 7.44 ± 1.81 | −5.83 | .000 |
Expressiveness | 4.23 ± 1.86 | 5.13 ± 1.75 | −2.59 | .011 |
Conflict | 4.48 ± 2.78 | 3.17 ± 1.97 | 3.84 | .000 |
Independence | 5.08 ± 1.58 | 4.84 ± 1.54 | 1.06 | .291 |
Achievement | 5.66 ± 1.71 | 5.81 ± 1.55 | −0.65 | .518 |
Intellectual-Cultural | 3.23 ± 1.96 | 4.39 ± 1.96 | −4.08 | .000 |
Active-Recreational | 2.98 ± 2.20 | 4.74 ± 2.23 | −5.51 | .000 |
Moral-Religious | 4.52 ± 1.69 | 5.24 ± 1.39 | −3.25 | .001 |
Organization | 4.86 ± 1.87 | 5.94 ± 1.85 | −4.00 | .000 |
Control | 3.14 ± 1.80 | 3.36 ± 1.85 | −0.84 | .403 |
Note: statistical significance was set at
Our second aim was to explore the relationship between the severity of depression and cognitive distortion, type D personality, adverse family environment, and socioeconomic status. Pearson correlation analysis between depression severity and cognitive distortion, Type D personality, family environment and socioeconomic status was reported as follows: depression severity negatively related to Optimism (
In order to confirm whether Optimism, Type D personality, Cohesion in family environment factors may influence of depression, we performed hierarchical linear regression to analyze the effect of different variables on depression (refer to Table
Hierarchical regression analysis of significant factors predicting depression.
Model | Adjusted | SE | ||||
---|---|---|---|---|---|---|
Model 1 | .589 | |||||
optimism | −2.281 | .137 | −.769 | −16.650 | .000 | |
Model 2 | .641 | |||||
optimism | −1.443 | .201 | −.486 | −7.176 | .000 | |
NA | .535 | .099 | .366 | 5.400 | .000 | |
Model 3 | .660 | |||||
optimism | −1.322 | .199 | −.445 | −6.637 | .000 | |
NA | .468 | .099 | .320 | 4.752 | .000 | |
Cohesion | −.685 | .294 | −.163 | −3.357 | .001 | |
Model 4 | .668 | |||||
optimism | −1.265 | .198 | −.426 | −6.385 | .000 | |
NA | .461 | .097 | .315 | 4.735 | .000 | |
Cohesion | −.587 | .206 | −.140 | −2.857 | .005 | |
Intellectual-cultural | −.531 | .222 | −.107 | −2.389 | .018 |
Note
A path analysis was conducted to determine which factor directly influenced depression, which one indirectly influenced it (refer to Figure
Path analysis of depression in adolescents. Note: the figure represented
(1) optimism → depression, (2) NA → depression, (3) NA → optimism → depression, (4) cohesion → NA → depression, (5) cohesion → NA → optimism → depression.
To date, few studies have been conducted generally on cognitive distortion, type D personality, and family environment in adolescents with depression. The current study investigated the relationship between different associated factors and depression in a sample of Chinese adolescents. Firstly, we aimed to study the association between cognitive distortion and depression in Chinese adolescents. Consistent with previous findings [
Another finding in our study suggests that Chinese-depressed adolescents display obviously type D personality comparing to normal controls. Negative affectivity (NA) and social inhibition (SI) are two traits of type D. Our findings indicate that Chinese adolescents with type D personality trait were prone to depressive symptoms, type D was related to increased risk of depression, in addition, NA and SI showed positive correlation with depression, and NA characteristic was significantly associated with depression. The depressed adolescents with type D personality tended to perceive distress emotion and experience unhappy life events. Their social activities may be prone to self inhibition due to worry refusal in communication. Pedersen et al. proved that type D personalities were associated with close to a 3-fold increased risk of developing depressive symptoms [
Our study revealed that poor family cohesion and conflict were associated with increased risks of depression in Chinese adolescents. Chinese researches (Liu et al., 2008) found that low cohesion (OR: 3.07, 95%CI: 1.67–5.67) and high conflict (OR: 4.94, 95%CI: 2.92–8.37) may predict suicidal ideation or attempt of Chinese adolescents [
We constructed depression diathesis model to examine the contribution to depression. Path analysis indicated that optimism variable had direct impact on depression, and it had stronger contribution to depression. However, while NA and cohesion variable also had a direct impact on depression, their respective contributed values were minor. In addition, we found that NA had a stronger impact on optimism; we speculated that NA as a predisposition may indirectly influence depression. And cohesion had a impact on NA, showing an important influence of family environment on development of adolescent personality. Generally, the interaction of all variables leads to an understanding of the multifactorial nature of depression [
Our study has numerous limitations. Firstly, our patient samples were recruited from hospital clinic rather than community; the depressed and healthy controls were almost drawn from urban area and cannot be considered representative of the all adolescent population, we did not investigate adolescents from rural area. Some researchers found that Chinese adolescents from rural area reported more likely to depression even suicidality [
In summary, our findings indicate that Chinese-depressed adolescents display obviously low levels of optimism, type D personality, family conflict, and poor family cohesion. Of these risks, low levels of optimism and negative affectivity may significantly be associated with depression in Chinese adolescents. The findings from current study seem to suggest low levels of optimism, negative affectivity, and poor family cohesion contributed to depression among Chinese adolescents. Our study may provide some meaningful methods to evaluate the depression in adolescents, we should sufficiently pay attention on these increasing risks in course of targeted interventions and preventive efforts in this population.
The authors thank all doctors and nurses who participated in our study in the Second Affiliated Hospital of Xinxiang Medical College for technical assistance. Moreover, they thank all adolescents for their participation.